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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200476
Report Date: 09/22/2021
Date Signed: 09/22/2021 06:24:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/26/2021 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20210326142557
FACILITY NAME:HEART AND SOUL COMMUNITIES IIFACILITY NUMBER:
019200476
ADMINISTRATOR:GEORGE ANDRE SMITHFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 686-1567
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:6CENSUS: 9DATE:
09/22/2021
UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Ericka Tillis, Administrator/LicenseeTIME COMPLETED:
06:45 PM
ALLEGATION(S):
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Medications are accessible to residents.
Living room in facility is being used as a bedroom.
Facility is not in good repair.
Facility is not clean.
INVESTIGATION FINDINGS:
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On 9/22/2021 starting at 3:20pm, Licensing Program Analysts (LPAs) L. Francisco and L. Hall conducted an unannounced complaint investigation for the allegatives above. LPAs met with Administrator/Licensee, Ericka Tillis.

During the course of the investigation, LPA L. Francisco obtained information, interviewed staff and conducted a tour of facility on 9/22/2021.

Allegation: Medications are accessible to residents

Based on documents obtained from 4/5/2021, unlocked medications were being stored on top of dresser located in the living room upstairs during the time family members were occupying the living room..

REPORT CONTINUES ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/26/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210326142557

FACILITY NAME:HEART AND SOUL COMMUNITIES IIFACILITY NUMBER:
019200476
ADMINISTRATOR:GEORGE ANDRE SMITHFACILITY TYPE:
740
ADDRESS:2245 SOL STREETTELEPHONE:
(510) 686-1567
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:6CENSUS: 9DATE:
09/22/2021
UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Ericka Tillis, Administrator/LicenseeTIME COMPLETED:
06:45 PM
ALLEGATION(S):
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2
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9
Facility is providing unsafe accommodations.
Facility is malodorous.
Uncleared individual residing in facility
Facility is not following infection control
INVESTIGATION FINDINGS:
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On 9/22/2021 starting at 3:20pm, Licensing Program Analysts (LPAs) L. Francisco and L. Hall conducted an unannounced complaint investigation for the allegatives above. LPAs met with Administrator/Licensee, Ericka Tillis.

During the course of the investigation, LPA L. Francisco obtained information, interviewed staff and conducted a tour of facility on 9/22/2021.

Allegation: Facility is providing unsafe accommodations.

Based on information obtained, living room was being used as a bedroom. However, interview with S1 revealed S1's family members are independent and does not require care.

REPORT CONTINUES ON 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20210326142557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HEART AND SOUL COMMUNITIES II
FACILITY NUMBER: 019200476
VISIT DATE: 09/22/2021
NARRATIVE
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Allegation: Facility is malodorous.

During the tour of facility on 9/22/2021, LPAs did not observe the smell of human waste nor body odor.

Allegation: Uncleared individual residing in facility

Interview with S1 revealed S1's family members were not cleared and was temporarily living in the facility. However, PIN 20-12-CCLD was issued on May 8, 2020 waiving background clearance. LPAs were unable to confirm whether S1's family members moved out of the facility before waiver expired.

Allegation: Facility is not following infection control

Based on record review and interview, although facility had a COVID-19 positive case, facility informed appropriate agencies and followed COVID-19 protocols according to CCLD and local DPH guidance.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20210326142557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HEART AND SOUL COMMUNITIES II
FACILITY NUMBER: 019200476
VISIT DATE: 09/22/2021
NARRATIVE
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Allegation: Living room in facility is being used as a bedroom.

Interview with S1 revealed S1's family members were occupying the living room temporary during COVID-19 pandemic.

Allegation: Facility is not in good repair.

Based on observation on 9/22/2021 and documents obtained from 4/5/2021, LPAs observed double door at front entrance is in disrepair. LPAs observed double door does not latch closed when locked and wood is chipped which causes a gap in between the doors.

Allegation: Facility is not clean

On 9/22/2021 during a tour of the facility, LPAs observed second floor of facility is cluttered with boxes of decorations due to a remodel.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20210326142557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HEART AND SOUL COMMUNITIES II
FACILITY NUMBER: 019200476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2021
Section Cited
CCR
87465(h)(2)
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Incidental Medical and Dental Care
The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons...

This requirement was not met as evidenced by:
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Deficiency cleared. LPAs observed medications were no longer being stored in living and inaccessible to residents.

In addition, Adminstrator will review regulation and conduct training with staff ands submit to CCL by 10/8/2021.
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Based on interview and record review, Licensee did not comply with regulation cited above. LPAs observed medications stored above dresser located in living room which poses an immediate health and safety risk to residents in care.
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Type B
09/22/2021
Section Cited
CCR
87307(a)
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Personal Accomodations and Services
(a) Living accommodations and grounds shall be related to the facility's function...

This requirement was not met as evidenced by:
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Deficiency cleared. LPAs observed living room is accessible to residents

In addition, Administrator agrees to review regulation and send self-certification letter to CCL by 10/8/2021
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Based on record review and interview, Licensee did not comply with regulations cited above. It was revealed that living room on the second floor was being occupied as a bedroom which poses a potential personal rights to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20210326142557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HEART AND SOUL COMMUNITIES II
FACILITY NUMBER: 019200476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2021
Section Cited
CCR
87303(a)
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5
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7
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times...
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By POC date, Administrator agrees to submit a copy of facility's construction timeline to CCL.
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Based on observation, Licensee did not comply with the regulations cited above. LPAs observed front entrance double door was in disrepair and boxes of decorations were observed on second floor which poses a potential personal rights to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6